Provider Demographics
NPI:1619342904
Name:CHAN, WAI SI (LMFT)
Entity Type:Individual
Prefix:
First Name:WAI SI
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:3880 S BASCOM AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-2600
Mailing Address - Country:US
Mailing Address - Phone:408-351-1044
Mailing Address - Fax:
Practice Address - Street 1:3880 S BASCOM AVE STE 115
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-2600
Practice Address - Country:US
Practice Address - Phone:408-351-1044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-11
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT 84700106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist